Download The role of ophthalmic triage and the nurse practitioner in

The role of ophthalmic
S. BANERJEE, S. BEATTY, A. TYAGI,
G.R. KIRKBY
triage and the nurse
practitioner in an eye­
dedicated casualty
department
The purpose of an ophthalmic casualty
department is to manage ocular emergencies.
However, previous studies have shown that a
substantial proportion of those attending
ophthalmic accident and emergency (A&E)
departments have non-acute problems that
would be more appropriately referred to the
ophthalmic outpatient department and that the
majority of conditions seen could be accurately
treated by the general practitioner (GP).1-3
Nevertheless, the guarantee of same-day service
and a specialist opinion in an eye-dedicated
A&E department indicates that inappropriate
GP referrals and self-referrals are likely to
continue.
The wide variation in the severity of
conditions seen and the high attendance has
prompted many ophthalmic casualty units to
introduce a triage system that allocates a patient
to the appropriate category of urgency.
Furthermore, the role of the nurse practitioner
(NP) in ophthalmology has been expanded in
recent years in an effort to provide a cost­
effective means of reducing waiting times while
maintaining a high standard of patient care.
The casualty department of the Birmingham
and Midland Eye Centre (BMEC) provides a
24 h service for acute ophthalmic conditions.
This unit relies on a triage system and a NP if it
is to deliver an efficient service. We
prospectively evaluated the performance of the
NP and the triage system in our unit.
Abstract
Purpose To evaluate the appropriateness of
triage decisions in a busy ophthalmic casualty
department and to assess the diagnostic and
management skills of eye-dedicated nurse
practitioners.
Methods Three hundred and one consecutive
patients attending the Birmingham and
Midland Eye Centre (BMEC) accident and
emergency (A&E) department over a 2 week
period were included in this prospective
study. Patients were categorised in terms of
urgency in concordance with strict guidelines,
and the agreement between the final diagnosis
and this system of prioritisation was then
investigated. To evaluate nurse practitioner
(NP) skills, all patients seen and managed by a
NP were also assessed by the most senior
doctor in casualty at the time in a masked
fashion. Waiting times and a breakdown of
waiting times were also calculated.
Results Upon establishment of a diagnosis,
triage category allocation was found to be
appropriate in all 301 cases. Fifty patients
(16.67%) were seen by the NP. Of these the
supervising doctor concurred with the NP
diagnosis in all cases and with the proposed
management in 96% of cases. The mean
waiting time (::!:: SD) was 83.43 ::!:: 45.84 min,
with a range of 5-335 min. The delay before
being attended to was greater for less urgent
cases as categorised by the triage system.
Conclusion This study confirms the high
S. Banerjee
standard of diagnostic and management skills
S. Beatty
of the ophthalmic NP and indicates that the
Materials and methods
A. Tyagi
G. R. Kirkby
triage system of patient prioritisation is
All patients attending the A&E department of
the BMEC over a 2 week period were included
in this study. Attached to each patient's casualty
card was a specially designed form to collect the
following information: source of referral,
demographic data, presenting complaint, triage
category, diagnosis, management, plan for
follow-up, waiting time. The ophthalmic triage
is based on a colour-coding system, the different
categories of urgency being allocated a red,
yellow, green or white card. In addition, certain
Birmingham and Midland
Eye Centre
accurate. Waiting times in the A&E
department remain unacceptable and ways of
Birmingham, UK
addressing this include improved ophthalmic
S. Banerjee k'!5J
training of general practitioners, diverting a
Birmingham and Midland
greater proportion of non-acute cases to the
Eye Centre
primary care clinic and expanding the role of
City Hospital NHS Trust
Dudley Road
the NP.
Birmingham B18 7QH, UK
Tel: +44 (0)121 554 3801
Fax: +44 (0)121 507 6853
880
Key words Casualty, Nurse practitioner, Triage
Eye (1998) 12, 880-882 © 1998
Royal College of Ophthalmologists
presenting complaints are not seen in the A&E
department but are diverted to the appropriate clinics,
including the primary care clinic (watery eyes, ectropion,
entropion and glaucoma suspects) and the 'lid lump'
clinic (chalazia and other lid lesions).
Category red is reserved for those conditions that
need to be seen immediately and includes perforating
eye injuries, severe trauma, alkali burns, total hyphaema,
complete loss of visual acuity over the previous 48 h and
acute medical conditions. Patients with partial loss of
visual acuity within the previous 48 h, ocular pain, blunt
trauma or acute medical conditions, in addition to young
children (0-3 years) and those requiring admission, are
classed in category yellow and should be seen within half
an hour.
We aim to see category green complaints within 1 h of
arrival. These include diplopia, blurred and distorted
vision of recent onset (within the previous 48 h), iritis,
episcleritis, allergic eye disease, corneal ulcers, suture­
related complaints and post-operative problems, as well
as in-patients at other hospitals, ambulance patients and
children between 4 and 10 years of age.
The NP attends to category white conditions, some of
which may require follow-up in the primary care clinic.
These include subconjunctival haemorrhage, dry eyes,
trichiasis, blepharitis, conjunctivitis (bacterial and viral),
corneal abrasions and corneal foreign bodies. For the
purposes of this study, all category white patients were
reviewed by the casualty doctor in a masked fashion in
order to assess whether the NP diagnosis and
management were appropriate.
Results
Four hundred and seventy-two patients attended our
A&E department during the study period. Only 301 of
these cases had sufficiently completed audit forms to be
included in the study (we excluded all partially
completed forms). The mean age (± SD) of the group was
45.98 ± 23.93 years and the male-to-female ratio was
65:35. The relative proportions of each ethnic group
were: Caucasian 228 (76%), Asian 38 (12.67%), Afro­
Caribbean 22 (7.33), Oriental 13 (4.33%).
The triage colour-coding system categorised patients
as follows: red 31 (10.33%), yellow 31 (10.33%), green 188
(62.67%), white 50 (16.67%). These code allocations were
deemed appropriate in all cases when reviewed by the
supervising doctor, who was the most senior grade of
doctor in the department at the time.
The mean waiting time (± SD) was 83.43 ± 45.84 min,
with a range of 5-335 min. The delay before being
attended to was greater for less urgent cases (Table 1).
The time interval between triage assessment and
consultation with the ophthalmologist was the greatest
source of delay for all our cases, regardless of the triage
category. Fifty patients (16.67%) were seen by the NP.
The supervising doctor saw all these patients
subsequently without knowledge of the NP's diagnosiS
or proposed management plans. The doctor concurred
with diagnOSiS in all cases and with the proposed
Mean and range of waiting times for different triage
categories at the ophthalmic casualty department of the Birmingham
and Midland Eye Centre
Table 1.
Triage category
Waiting time
Red
Yellow
Green
Mean
Range
47.6
88.1
143.7
54.3
5-112
10-133
20-335
5-181
White
management in 96% of cases (48 patients). Discrepancies
between the planned management of the
ophthalmologist and the NP were minor and included
whether or not to use an eyepad (1 case) and the
frequency of topical lubricants (1 case).
Discussion
The effectiveness of ophthalmic triage and eye-dedicated
NPs has not been investigated previously, although one
study has commented favourably on the contribution of
the ophthalmic NP. l We believe health services research
such as this is essential in the planning of local services.
Triage, initially developed by military surgeons to
deal with the large number of war casualties,4 is
designed to ensure that patients with conditions
requiring urgent treatment are seen first. In a busy
casualty unit such as ours, those needing early medical
or surgical intervention would be lost in the large
number of waiting patients if a system of patient
prioritisation were not in use. The results of this study
indicate that the ophthalmic triage is providing an
effective means of streamlining the urgent cases and that
the categorisation of ocular conditions was appropriate.
The success of patient prioritisation depends, however,
on adequate training of ophthalmic nurses, and clear
guidelines for each colour code being readily available.s
Furthermore, the triage system should be explained to
casualty attendees to prevent the perception that some
patients are 'jumping the queue'.
Although the more urgent cases were seen earlier
than those with less serious conditions, our target
waiting times were not met and remain unacceptable.
The greatest source of delay in all triage categories was
the interval between the nursing assessment and the
doctor's evaluation. In view of the fact that an increase in
medical staffing is unlikely, there appear to be only two
ways of ensuring that casualty patients are seen more
swiftly. The first is to reduce the number of people
attending the department, and this could be achieved if
CPs managed a greater proportion of cases themselves
and redirected the more non-acute cases to the primary
care clinic. The former would require regular,
ophthalmologist-led training programmes in eye care to
enhance the confidence of local CPs in the management
of ocular disease, and the latter involves deploying more
human resources in primary care clinics. Another
method of reducing waiting times would be to further
expand the role of the NP so as to regulate the inflow of
881
patients who have been seen by another professional
accessibility and less expensive emergency ophthalmic
(GP, 00, etc.) by offering an appointment-based
services for the local community without compromising
emergency referral service.
the quality of care.
At our hospital the ophthalmic nurses undergo a
structured training programme before taking up
In conclusion, we found the eye-dedicated NP and
triage to be crucial in the effective management of a busy
responsibilities as a NP. They are usually 'E' grade
ophthalmic A&E unit. The system of patient
nurses who have already worked in the ophthalmic
categorisation in terms of urgency is accurate and the
department for at least 6 months. They spend another 6
high standard of diagnostic and management skills of the
months training with the doctors or NPs. At the end of
ophthalmic NP is confirmed.
this period they are assessed by the Registrars and, if
Waiting times in the A&E department remain
found successful, they can work as a NP. The NPs in this
unacceptable and ways of addressing this include
study had been practising for an average of 1-2 years.
improved ophthalmic training of GPs, diverting a greater
Besides a slit lamp with television monitor they have
proportion of non-acute cases to the primary care clinic
access to other instruments necessary for managing
and expanding the role of the NP.
minor ocular problems. The NPs at our hospital carry out
procedures such as removal of corneal foreign body,
epilation of eyelashes, donor eye retrieval and incision
and curettage of cysts. They also manage patients with
corneal abrasion, arc eye and conjunctivitis.
In our study there was 100% concordance between the
ophthalmologist's and NP's diagnosis and the two types
of health care professionals were in agreement in 96% of
cases regarding proposed management. The two
differences in management would not have resulted in
adverse outcome. This finding indicates that the quality
of care delivered by ophthalmic NPs for category white
conditions is comparable to that provided by
ophthalmologists. This is consistent with the results of a
survey of NP schemes in England and Wales, and that
study also noted that non-physician health care
professionals were more frequently utilised in
6
ophthalmic than other casualty departments. On the
basis of this study and the cost-effectiveness of NPs, we
believe that NP programmes will result in increased
882
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